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Hyperemesis Gravidarum (Case Study)

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

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Hyperemesis gravidarum.

Lindsey K. Jennings ; Heba Mahdy .

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Last Update: September 6, 2022 .

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia. There is no consensus on specific diagnostic criteria, but it generally refers to the severe end of the spectrum regarding nausea and vomiting in pregnancy. This activity highlights the role of the interprofessional team in the prevention and management of hyperemesis gravidarum.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia. [1] [2]  There is no consensus on specific diagnostic criteria, but it generally refers to the severe end of the spectrum regarding nausea and vomiting in pregnancy. It occurs in approximately two percent of all pregnancies in the United States. [3]  It can significantly impact the quality of life of women and their families and, unfortunately, may be very challenging to treat. [4]

The etiology of hyperemesis gravidarum is largely unknown, but several theories exist (see pathophysiology). There are, however, risk factors associated with the development of hyperemesis during pregnancy. Increased placental mass in the setting of a molar or multiple gestations has been associated with a higher risk of hyperemesis gravidarum. Additionally, women who experience nausea and vomiting outside of pregnancy due to the consumption of estrogen-containing medications, exposure to motion, or have a history of migraines are at higher risk of experiencing nausea and vomiting during pregnancy. Some studies also suggest a higher risk of hyperemesis in women with first-degree relatives, for instance, if her mother or sister experienced hyperemesis gravidarum. [5]

Protective factors include the use of multivitamins before six weeks of gestational age and maternal cigarette smoking. [6]

Up to ninety percent of women experience nausea during pregnancy. Studies showed that approximately 27 to 30 percent of women experience only nausea, while vomiting may be seen in 28 to 52 percent of all pregnancies. [7] [8]  The incidence of hyperemesis gravidarum ranges from 0.3 to 3 percent, depending on the literature source. Geographically, hyperemesis appears to be more common in western counties. [9]

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process.

Hormone Changes

Changes in the Gastrointestinal System

Careful history taking in women with suspected or confirmed hyperemesis gravidarum should include their pregnancy status, estimated gestational age, history of complications during prior pregnancies, the frequency and severity of nausea and vomiting, any interventions done to treat her symptom(s), and the outcomes of the attempted interventions. The average onset of symptoms happens approximately 5 to 6 weeks into gestation. [8]

The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

There is no single accepted definition for hyperemesis gravidarum. However, it generally refers to extreme cases of nausea and vomiting during pregnancy. It is a clinical diagnosis. The criteria for diagnosis include vomiting that causes significant dehydration (as evidenced by ketonuria or electrolyte abnormalities) and weight loss (the most commonly cited marker for this is the loss of at least five percent of the patient’s pre-pregnancy weight) in the setting of pregnancy without any other underlying pathological cause for vomiting. Significant abdominal tenderness, pelvic tenderness, or vaginal bleeding should prompt a workup for alternative diagnoses.

The evaluation should include urinalysis to check for ketonuria and specific gravity, in addition to a complete blood count and electrolyte evaluation. An elevation in hemoglobin or hematocrit may be due to hemoconcentration in the setting of dehydration. Significant dehydration may result in acute kidney injury as evidenced by elevated serum creatinine, blood urea nitrogen, and reduced glomerular filtration. Potassium, calcium, magnesium, sodium, and bicarbonate may be affected by prolonged bouts of vomiting and reduced oral intake of fluids. Thyroid tests, lipase, and liver function testing may also be completed to evaluate for alternate diagnoses.

Radiographic studies may be appropriate to rule out alternate diagnoses. Obstetrical ultrasounds may be considered to rule out multiple gestations, ectopic pregnancy, and gestational trophoblastic disease, depending on the patient’s history and prior obstetrical evaluations. Magnetic resonance imaging (MRI) may be used to assess alternative diagnoses, such as appendicitis.

Treatment should be guided by the American College of Obstetrics and Gynecology (ACOG) Nausea and Vomiting in Pregnancy guidelines. Initial treatment should begin with non-pharmacologic interventions such as switching the patient’s prenatal vitamins to folic acid supplementation only, using ginger supplementation (250 mg orally 4 times daily) as needed and applying acupressure wristbands. [16] [17]  If the patient continues to experience significant symptoms, the first-line pharmacologic therapy should include a combination of vitamin B6 (pyridoxine) and doxylamine. Three dosing regiments are endorsed by ACOG, including pyridoxine 10 to 25 mg orally with 12.5 mg of doxylamine three or four times per day, 10 mg of pyridoxine and 10 mg of doxylamine up to 4 times per day, or 20 mg of pyridoxine and 20 mg of doxylamine up to 2 times per day. These are all FDA pregnancy category A medications.

Second-line medications include antihistamines and dopamine antagonists such as dimenhydrinate 25 to 50 mg every 4 to 6 hours orally, diphenhydramine 25 to 50 mg every 4 to 6 hours orally, prochlorperazine 25 mg every 12 hours rectally, or promethazine 12.5 to 25 mg every 4 to 6 hours orally or rectally. If the patient continues to experience significant symptoms without exhibiting signs of dehydration, metoclopramide, ondansetron, or promethazine may be given orally. In the case of dehydration, intravenous fluid boluses or continuous infusions of normal saline should be given in addition to intravenous metoclopramide, ondansetron, or promethazine. Electrolytes should be replaced as needed. Severe refractory cases of hyperemesis gravidarum may respond to intravenous or intramuscular chlorpromazine 25 to 50 mg or methylprednisolone 16 mg every 8 hours, orally or intravenously. [18]

The diagnosis of hyperemesis gravidarum is clinical and largely a diagnosis of exclusion. The list of potential differential diagnoses for patients with similar symptoms is quite extensive. It can include: [19]

Gastrointestinal Conditions

Genitourinary Conditions

Metabolic Conditions

Neurologic Disorders

Miscellaneous Conditions

Psychologic Conditions

Pregnancy-related conditions

It is important to evaluate women presenting with (HG) for gestational trophoblastic disease (GTD) and multiple gestations as they may also present with severe nausea and vomiting in the first trimester of pregnancy. The workup may begin with an obstetric ultrasound scan, which will confirm the diagnosis in most cases. Other first-trimester obstetric concerns include ectopic pregnancy, which is more likely to include abdominal pain, syncope, or vaginal bleeding and can again be evaluated by obstetrical ultrasound and beta-hCG levels.

The onset of nausea and vomiting after nine weeks should spark concern for alternative diagnoses. Preeclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelets), and acute fatty liver of pregnancy typically present themselves during the late second or third trimester of pregnancy.

Non-obstetrical causes for nausea and vomiting can also occur during pregnancy and should always remain on the differential, keeping in mind that pregnant patients are considered to be at higher risk of blood clotting; therefore, diagnoses that result in ischemia or thrombus formation may be more common during pregnancy. Gastrointestinal causes such as gastroenteritis, small bowel obstruction, gastroparesis, peptic ulcer disease, cholecystitis, pancreatitis, hepatitis, and appendicitis should be considered. Pyelonephritis, urinary tract infections, renal stones, and ovarian torsion may also include vomiting. Metabolic derangements such as diabetic ketoacidosis, hyperthyroidism, and hyperparathyroidism may also have similar symptoms. Neurologic disorders such as migraine, intracranial hemorrhage, pseudotumor cerebri, and venous sinus thrombosis can also cause vomiting but are likely to have associated headaches or neurologic deficits. Psychiatric disorders such as anxiety and depression may also result in vomiting, toxic ingestions, and myocardial ischemia.

Validating the Effect of Ondansetron and Mirtazapine in Treating Hyperemesis Gravidarum: A Double-Blind Randomised Placebo-Controlled Multicentre Trial. (ongoing trial till 2023) Chewing Gum Containing Vitamin-c to Treat Emesis Gravidarum: a Randomized Controlled Trial. (ongoing trial till March 2022)

Modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE Score) 

No single measure can easily define, quantify or evaluate the treatment of hyperemesis. Still, an English pregnancy-specific questionnaire, PUQE (Pregnancy-Unique Quantification of Emesis), has been developed to assess the severity of emesis (nausea and vomiting) in pregnancy. This questionnaire contains three questions regarding the time-span of nausea, vomiting, and retching, respectively, as well as one question assessing the global psychological and physical quality of life (QOL). Initially, the questionnaire evaluated symptoms during the last 12 hours, but it has been modified to encompass 24 hours and the whole of the first trimester of pregnancy. [20]  PUQE-score has been validated to correlate with the inability to take iron supplementation in pregnancy, risk of hospitalization due to HG or severe nausea and vomiting in pregnancy (NVP), and increased health care costs due to NVP, and reduced well-being/QOL (quality of life).

Nausea and vomiting in pregnancy are common. Symptoms usually begin prior to 9 weeks gestation, and the majority of cases are resolved by week 20 of gestation. A minority of patients, approximately 3 percent, will continue to experience vomiting during the third trimester. Approximately 10 percent of patients with hyperemesis gravidarum will be affected throughout the pregnancy. [21]  It is reassuring to know that hyperemesis does not appear to become more likely with each pregnancy and that after one pregnancy with (HG), the following pregnancy may be different. [22]

As hyperemesis gravidarum involves at least two patients, both the mother and the fetus(s) must be considered when discussing complications.

Maternal Complications

In severe cases of hyperemesis, complications include vitamin deficiency, dehydration, and malnutrition, if not treated appropriately. Wernicke encephalopathy, caused by vitamin-B1 deficiency, can lead to death and permanent disability if left untreated. [23] [24] [25]  Additionally, there have been case reports of injuries secondary to forceful and frequent vomiting, including esophageal rupture and pneumothorax. [26] [27] [28]  Electrolyte abnormalities such as hypokalemia can also cause significant morbidity and mortality. [29]  Additionally, patients with hyperemesis may have higher rates of depression and anxiety during pregnancy. [30]

Fetal Complications

Studies report conflicting information regarding the incidence of low birth weight and premature infants in the setting of nausea and vomiting in pregnancy. [31] [32] [33] [34]  However, studies have not shown an association between hyperemesis and perinatal or neonatal mortality. [34]  The frequency of congenital anomalies does not appear to increase in patients with hyperemesis. [31]

Primary healthcare providers should refer women presenting with (HG) to obstetric providers as it is the most severe form of nausea and vomiting in pregnancy. Inpatient management is indicated for intravenous antiemetics and fluids in the setting of refractory symptoms, failed outpatient treatment, severe dehydration, or electrolyte disturbance. Management of women with (HG) should involve a multidisciplinary team to improve outcomes for both the mother and the baby.

Daily intake of a multivitamin with folic acid at least one month prior to conception not only reduces the risk of congenital anomalies such as neural tube defects but has also been associated with reduced frequency and severity of nausea and vomiting in pregnancy. [19]

Women presenting with HG should be managed by an interprofessional team that provides comprehensive care and an integrated approach to help achieve the best patient-centered outcomes. Midwives and primary health care providers should ensure timely referral of women with HG to avoid unnecessary delay in the most appropriate management of these women. Clear and legible communication among the interprofessional team members will help deliver the best standard of care for women with HG. Women with severe and intractable (HG) should be managed in the hospital, and the nurse should document all her observations accurately. The nurse should inform the obstetric provider of any untoward change in the maternal observations. Assessment of fetal wellbeing plays a very crucial role in the management of women with (HG). If there is any deterioration of the general condition of the woman with (HG), early transfer to critical care units should be considered. Intensivists and critical care team members should be involved in managing women presenting with severe and/or intractable (HG). The woman's preferences, views, and choices should be respected at all times. [Level 5]

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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HOWARD ERNEST HERRELL, MD

Am Fam Physician. 2014;89(12):965-970

Author disclosure: No relevant financial affiliations.

Nausea and vomiting of pregnancy affects nearly 75% of pregnant women. The exact cause is unknown. In most cases, it is a mild, self-limited condition that can be controlled with conservative measures and has no adverse fetal sequelae. About 1% of women develop hyper-emesis gravidarum, which may result in adverse outcomes for the mother and fetus. Patients with nausea and vomiting of pregnancy should be evaluated for other causes, particularly if symptoms are unremitting or presentation is atypical. Initial treatment is conservative and includes dietary changes, emotional support, and vitamin B 6 supplementation. Several safe and effective pharmacologic therapies are available for women who do not improve with initial treatment. Women with hyperemesis gravidarum may require more aggressive interventions, including hospitalization, rehydration therapy, and parenteral nutrition.

Nausea and vomiting occur in up to 74% of pregnant women, and 50% experience vomiting alone. 1 , 2 Although the term morning sickness is commonly used to describe nausea and vomiting of pregnancy, the timing, severity, and duration of symptoms vary widely. Approximately 80% of women report that their symptoms last all day, whereas only 1.8% report symptoms that occur solely in the morning. 2

Women who are less educated, older, or black, and those who have lower incomes, multiple gestations, or increasing gravidity (including miscarriages) are at greater risk of nausea and vomiting of pregnancy. 1 A personal history of motion sickness, 3 migraine headaches, 4 or nausea associated with the use of estrogen-containing contraceptives 5 also increases the risk.

Hyperemesis gravidarum describes nausea and vomiting that is severe enough to cause fluid and electrolyte disturbances, and often requires hospitalization. 6 It affects up to 1% of pregnant women and is associated with persistent vomiting (more than three episodes per day) that results in severe dehydration, ketonuria, electrolyte abnormalities such as hypokalemia, and weight loss of more than 5%. 7 , 8 A personal history of hyperemesis gravidarum, gestational trophoblastic disease, fetal triploidy, fetal trisomy 21, hydrops fetalis, and multiple gestations increases the risk of this condition. 9 The risk may be increased by as much as 50% if the fetus is female. 10

Etiology and Pathophysiology

The causes of nausea and vomiting of pregnancy and of hyperemesis gravidarum are unknown. However, observational data indicate that these conditions correlate with levels of human chorionic gonadotropin (hCG) and the size of the placental mass, which suggests that placental products may be associated with the presence and severity of nausea and vomiting. 11 Some women with complete hydatidiform molar pregnancies, in which no fetus is present, have significant nausea and vomiting, which indicates that placental factors, particularly hCG, are responsible. Women with higher hCG levels, such as those with multiple gestations, hydatidiform moles, or fetuses with Down syndrome, are at increased risk of nausea and vomiting. 12

Levels of estrogen and progesterone may also be involved. Other potential etiologies include placental prostaglandins, serotonin levels, thyroid dysfunction, increased leptin levels, immune system dysregulation, Helicobacter pylori infection, and gastrointestinal dysmotility. 11

Differential Diagnosis

In most pregnancies, nausea and vomiting is mild and self-limited. It usually starts within four weeks of the last menstrual period and peaks at nine weeks' gestation. An estimated 60% of cases resolve by the end of the first trimester, and 87% resolve by 20 weeks' gestation. 13 Women who have atypical presentations (e.g., onset of symptoms after nine weeks' gestation, symptoms beyond the first trimester, severe symptoms, hyperemesis gravidarum) should be evaluated to exclude potentially serious causes ( Table 1 ) .

In women with straightforward nausea and vomiting of pregnancy, physical examination findings are generally unremarkable. Abnormal findings (e.g., abdominal tenderness, peritoneal signs, fever) suggest another cause. In the absence of other physical findings, significant dehydration, with or without orthostasis, is consistent with hyperemesis gravidarum.

No laboratory tests are necessary in patients with normal examination findings and no evidence of dehydration. If not already performed, ultrasonography may be used to evaluate for the presence of a molar pregnancy or multiple gestation if there is clinical suspicion or abnormally elevated hCG levels.

If laboratory tests are ordered because of clinical suspicion that symptoms are not caused by straightforward nausea and vomiting of pregnancy, a basic approach should include a complete blood count; urinalysis; metabolic panel including transaminase levels; and measurement of thyroid-stimulating hormone, quantitative hCG, and amylase levels. An abnormally high hCG level suggests a multiple gestation, molar pregnancy, or, in rare cases, a twin pregnancy with both a normal fetus and a molar gestation.

Maternal and Fetal Outcomes

In pregnancies with uncomplicated nausea and vomiting, there is a decreased risk of miscarriage, as well as lower rates of preterm delivery, fetal death, and growth restriction. 14 , 15 However, infants of women who lost weight early in the pregnancy, particularly in the setting of hyperemesis gravidarum, are at increased risk of growth restriction or low birth weight. 16 Women with nausea and vomiting that is refractory to treatment or complicated by weight loss have increased risks of fetal growth restriction and fetal death, as well as preeclampsia and maternal complications associated with vomiting (e.g., esophageal rupture, retinal hemorrhage, Mallory-Weiss syndrome, pneumothorax). 17 , 18

Treatment should be directed toward reducing symptoms while posing the least amount of risk to the fetus and mother. Various modalities have been used, some without evidence of benefit.

NONPHARMACOLOGIC THERAPIES

Traditional first-line therapy for nausea and vomiting of pregnancy and for hyperemesis gravidarum includes dietary modifications such as avoidance of large meals and consumption of low-fat, low-fiber, bland foods (e.g., breads, crackers, cereals, eggs, tofu, lean meat, peanut butter, fruits, vegetables). Avoidance of foods with strong smells and those with increased protein and liquid content is often recommended. 19 However, there is little evidence to support these recommendations.

Although nausea and vomiting of pregnancy and hyperemesis gravidarum have been linked with a variety of psychological conditions, including depression and stress-related disorders, more recent data have not shown a definitive association. 20 Evidence shows that women appreciate acknowledgment of the distress caused by nausea and vomiting of pregnancy and hyper-emesis gravidarum. 21

A variety of other nonpharmacologic therapies for nausea and vomiting of pregnancy are listed in Table 2 . 22 – 31 Although commonly used by patients and recommended by health care professionals, most of these treatments have only limited evidence supporting their benefit.

PHARMACOLOGIC THERAPIES

Vitamin B 6 and Doxylamine. Vitamin B 6 (10 to 25 mg every eight hours) is more effective than placebo in improving symptoms of nausea, although the reduction in vomiting is less clear 32 , 33 ( Table 3 ) . Combination therapy with vitamin B 6 and doxylamine (Unisom SleepTabs) reduces nausea and vomiting by 70%. 34 Although there have been concerns about teratogenicity, a large meta-analysis showed that combination therapy with vitamin B 6 and doxylamine is safe for use in the first trimester, 35 and it is recommended for treatment of nausea and vomiting of pregnancy by the American College of Obstetricians and Gynecologists. 34 In 2013, the U.S. Food and Drug Administration approved a delayed-release formulation of doxylamine and pyridoxine hydrochloride (Diclegis).

Antiemetics . Chlorpromazine and prochlorperazine have been shown to reduce symptoms of nausea and vomiting of pregnancy and of hyperemesis gravidarum. 36 Buccal administration of prochlorperazine is associated with less sedation than oral administration. 37 Promethazine is commonly used, but is sedating. It is available as a rectal suppository and can be compounded as a topical agent that is applied to the wrist. Its safety in the first trimester has been established. 38

Small studies have shown comparable effectiveness between ondansetron (Zofran) and promethazine in treating nausea and vomiting, although patients receiving ondansetron had less sedation. 39 Ondansetron is significantly more expensive than promethazine. The use of ondansetron in pregnancy has not been shown to increase the risk of miscarriage, major malformations, or low birth weight. 40

Antihistamines and Anticholinergics . Antihistamines decrease stimulation of the vomiting center by affecting the vestibular system. 11 Diphenhydramine (Benadryl), meclizine (Antivert), and dimenhydrinate have been shown to be safe and more effective than placebo in reducing the symptoms of nausea and vomiting of pregnancy. 36 Although scopolamine is likely effective, its use in the first trimester is not recommended because of the potential for limb and trunk defects. 41

Promotility Agents . Metoclopramide (Reglan) is often used alone and in combination with other agents, such as vitamin B 6 , for the treatment of nausea and vomiting of pregnancy. As a promotility agent, it increases gastric transit and lowers esophageal sphincter pressure. It is as effective as promethazine, but has fewer adverse effects. 42 Metoclopramide in combination with vitamin B 6 is more effective than prochlorperazine or promethazine, although all three therapies improve symptoms. 43 Because metoclopramide is associated with tardive dyskinesia, the U.S. Food and Drug Administration has issued a boxed warning. The risk of this rare complication increases with total dosage and duration of treatment; therefore, it should not be used for longer than 12 weeks.

Corticosteroids . A study involving 40 women found that methylprednisolone is superior to promethazine in reducing symptoms of nausea and vomiting in patients with hyperemesis gravidarum. 44 However, a meta-analysis of four studies found that the use of glucocorticoids before 10 weeks' gestation is associated with a three- to fourfold increased risk of cleft lip. 45 Therefore, glucocorticoids should be used only after 10 weeks' gestation.

Intravenous Fluids . Fluid replacement is safe and effective in restoring volume and electrolytes in women who have hyperemesis gravidarum and are unable to tolerate oral intake. Lactated Ringer solution or normal saline is acceptable. Because of the risk of Wernicke encephalopathy, intravenous thiamine should be added if dextrose-containing fluids are administered, if vomiting has lasted longer than three weeks, or if fluid replacement lasts longer than three days. 46

Enteral and Parenteral Nutrition . Patients who have refractory nausea and vomiting may require hospitalization. In these patients, enteral tube feeding in addition to routine intravenous fluids may be helpful. If patients do not respond to this therapy, parenteral nutrition may be necessary. 47 Administration of parenteral nutrition is associated with significant risk during pregnancy, including a 25% risk of line sepsis, as well as steatohepatitis if lipid emulsion is used. 48 Therefore, it should be reserved for extreme cases that have been refractory to enteral nutrition.

Acid-Reducing Medications . Recent data indicate that pregnant women who have acid reflux have more severe nausea and vomiting. 49 Histamine H 2 antagonists and proton pump inhibitors are safe and effective for use in pregnant women, and may improve nausea and vomiting.

OVERALL APPROACH TO TREATMENT

Nausea and vomiting of pregnancy is a common and sometimes challenging problem, and hyperemesis gravidarum may be associated with adverse perinatal outcomes. Both conditions may significantly affect the quality of life and psychological well-being of the mother. A variety of safe and effective therapeutic options are available, and a multimodal approach to treatment is helpful. The treatment algorithm presented in Figure 1 is closely aligned with treatment recommendations from the American College of Obstetricians and Gynecologists. 34

Data Sources : A PubMed search was completed using the key terms nausea and vomiting, pregnancy, and hyperemesis gravidarum. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Clinical Evidence, the Cochrane database, and Essential Evidence Plus were also searched. Search date: January 15, 2012, and January 24, 2014.

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Hyperemesis gravidarum: a short case study

09 August, 2001 By NT Contributor

VOL: 97, ISSUE: 32, PAGE NO: 55

JOY FIELD, RN, is clinical nurse specialist, clinical nutrition unit, Queen's Medical Centre, Nottingham

Hyperemesis gravidarum is a miserable condition for patients and a frustrating one for the staff caring for them. While nausea and vomiting are common and expected in early pregnancy, the syndrome of hyperemesis gravidarum, which can be defined as persistent vomiting starting in the first trimester, is relatively uncommon. A study in 1992 found that among 9,088 pregnancies 35 had hyperemesis of sufficient severity to require intravenous rehydration (Spiller, 1992).

Helen Bond, a 36-year-old single women pregnant with her first child, was transferred to the nutrition unit at 20 weeks of pregnancy with persistent vomiting and weight loss. On transfer she was mildly dehydrated and had ketonuria.

Ketonuria reflects the accelerated development of the starving state in the mother, which helps preserve glucose for the foetus. Despite the use of antiemetics and intravenous rehydration her symptoms did not settle: she vomited on the hour, every hour, day or night, and became tired, withdrawn and miserable. At a time when she should have enjoyed her pregnancy and 'blossoming' - this was a planned and wanted baby - she was wretched.

In view of Ms Bond's weight loss and the evidence from the foetal growth chart it was decided that parenteral nutrition should be started. A central venous catheter was inserted under image intensifier, a lead apron being used to cover the abdomen and protect the foetus from radiation. This gave protein, calories, vitamins and fluid and took the pressure off Ms Bond to try to eat and drink. Unfortunately it did nothing to stop her retching and vomiting.

Parenteral nutrition as a mode of nutritional support has increasingly been used for patients with hyperemesis gravidarum in recent years. A number of antiemetic agents were tried, including metoclopramide, domperidone and cyclizine - all safe during pregnancy - but without success. Although Ms Bond was not now vomiting such large amounts she had persistent retching with unrelenting nausea.

Ms Bond was managed with parenteral nutrition until her 34th week of pregnancy, when her vomiting stopped and she was discharged home. Vomiting started again at 36 weeks' gestation and an elective Caesarean section was performed at 37 weeks. She delivered a healthy boy weighing 3.1kg.

Intractable vomiting in hyperemesis gravidarum, despite minimal oral intake and antiemetic use, is unusual. Most patients respond to a short period of intravenous nutrition and antiemetic drugs. An elective Caesarean was performed because of concern for the mother's health and mental well-being. The immediate relief of symptoms on delivery confirmed the diagnosis of hyperemesis gravidarum, the causes of which are not known, although it is said to be more common in multiple pregnancy or in the presence of a hydratidiform mole. While drugs can be successful in suppressing vomiting, the sensation of severe nausea persists.

Our role in caring for Ms Bond was to monitor her physical signs, ensure accurate fluid balance recordings, perform weight and urine tests, prevent metabolic complications and care for her parenteral nutrition and central venous catheter correctly to prevent any infective complications occurring.

On the psychological side, we encouraged Ms Bond to be enthusiastic and interested in the baby, talking about it and looking forward to the birth, something not easy to achieve when she spent most of the day or night with her head in a bowl either vomiting or retching.

All normal antenatal care had to be abandoned. Ms Bond could not attend antenatal clinic or parentcraft sessions. This isolated her from the contact she would have had with other expectant mothers, important with a first baby and single mother. It made her pregnancy a period of illness and not normality. Although scans were placed in a diary as a record of the pregnancy, there was nothing normal about this pregnancy for Ms Bond.

It has to be difficult to be enthusiastic about anything in this situation, especially something that is making you feel so awful for so long. Caring for Ms Bond was both challenging and rewarding for the whole team in the nutrition unit and highlighted one of the rare and miserable complications of pregnancy.

After delivery, Ms Bond and her son bonded well. She successfully breast-fed him and was discharged home soon after delivery, vowing this would be her one and only pregnancy.

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After reading this article and taking this test, you should be able to:

1. The nausea and vomiting of hyperemesis gravidarum (HG) is particularly dangerous for pregnant women because it

a. has been associated with preeclampsia.

b. is a risk factor for gestational diabetes.

c. is a direct cause of postpartum depression.

d. prevents adequate intake of food and fluids.

2. The typical pattern of HG is that it begins between the

a. second and the fourth week of pregnancy.

b. fourth and the sixth week of pregnancy.

c. sixth and the eighth week of pregnancy.

d. eighth and the tenth week of pregnancy.

3. The symptoms of HG generally subside between the

a. sixth and the tenth week of pregnancy

b. tenth and the fourteenth week of pregnancy.

c. fifteenth and the twentieth week of pregnancy.

d. twenty-first and the fifth week of pregnancy.

4. Infants exposed to HG in utero are significantly more likely to have

a. a low birth weight.

b. congenital anomalies.

c. neonatal jaundice.

d. a postterm birth.

5. Bailit has demonstrated that infants exposed to HG in utero are more likely than others to die between which weeks of gestation?

a. 18 and 24.

b. 25 and 29.

c. 24 and 30.

d. 31and 35.

6. About how many cases of HG are reported annually in the United States?

7. Of the following ethnic groups of pregnant women, Grjibovski reported the highest incidence of HG among the women who are

a. Norwegian.

b. Pakistani.

c. British.

d. Turkish.

8. Of the following groups of pregnant women, Bailit reported the lowest incidence of HG among the women who are

d. Native American.

9. A current prevalent theory about the cause of HG is that it is primarily

a. socioeconomic.

b. neurological.

c. hormonal.

d. psychological.

10. Fejzo demonstrated that HG has an etiological component that is

a. psychosomatic.

b. pancreatic.

c. neuromuscular.

d. genetic.

11. According to the Hyperemesis Education and Research Foundation, a risk factor for HG is age

a. younger than 20 years.

b. between 21 and 25 years.

c. between 26 and 30 years.

d. older than 30 years.

12. A risk factor for HG is a diet high in

a. proteins.

b. simple carbohydrates.

c. saturated fats.

d. complex carbohydrates.

13. Which of the following is considered a risk factor for HG?

a. hypertension.

b. smoking.

c. first pregnancy.

d. thyroid disease.

14. The medication of choice for treating the symptoms of severe HG is

a. promethazine (Phenergan).

b. buclizine (Antivert).

c. hydroxyzine (Vistaril).

d. ondansetron (Zofran).

15. A dietary intervention helpful for women who have HG is

a. eating just one well-balanced meal per day.

b. eating toast before getting out of bed.

c. drinking lots of water and other fluids with meals.

d. avoiding low-fat protein foods such as boiled beans.

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Research Article

Determinants of hyperemesis gravidarum among pregnant women attending health care service in public hospitals of Southern Ethiopia

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization

Affiliation School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Software, Supervision, Validation, Visualization

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization

Roles Conceptualization, Data curation, Formal analysis, Investigation, Supervision, Validation, Visualization

* E-mail: [email protected]

Affiliation Department of Midwifery, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia

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Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Software, Supervision, Validation, Visualization

Affiliation School of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia

PLOS

Table 1

Hyperemesis gravidarum is severe nausea and excessive vomiting, starting between 4 and 6 gestational weeks, peak at between 8 and 12 weeks and usually improve and subside by 20 weeks of pregnancy. Identifying the determinants of hyperemesis gravidarum has a particular importance for early detection and intervention to reduce the health, psychosocial and economic impact. In Ethiopia there is low information on determinants of hyperemesis gravidarum.

Institution based unmatched case-control study design was conducted from April 12- June 12, 2021. A structured face-to-face interviewer administered questionnaire and checklist for document review were used to collect the data from 360 study participants (120 cases and 240 controls). The data were collected by KoBocollect 1.3, and then exported to statistical package for social science version 25 for further analysis. Both bi-variable and multivariable logistic regression analysis were done to identify the determinants and a p-value < 0.05 with a 95% confidence level was used to declare statistical significance.

Being an urban dweller (AOR = 2.1, 95% CI: 1.01, 4.34), having polygamous husband (AOR = 2.92, 95% CI: 1.27, 6.68), having history asthma/ other respiratory tract infections (AOR = 3.56, 95% CI: 1.43, 8.82), saturated fat intake (AOR = 4.06 95% CI: 1.98, 8.3), no intake of ginger (AOR = 3.04 95% CI: 1.14, 8.09), and inadequate intake of vitamin B rich foods (2.2, 95% CI: 1.14–4.2) were the determinants of hyperemesis gravidarum.

This study revealed that, urban residence, having polygamous husband, history of asthma/other respiratory tract infections, intake of saturated fat, no intake of ginger, inadequate intake of vitamin B reach foods were found to be independent determinants of hyperemesis gravidarum. It is better if healthcare providers and government authorities exert continual effort to give health education and counselling service concerning to dietary practice and asthma attacks. It is advisable if pregnant women adhere to healthy diets and limit intake of saturated fats and also husband and nearby relatives give care and support for pregnant women.

Citation: Ashebir G, Nigussie H, Glagn M, Beyene K, Getie A (2022) Determinants of hyperemesis gravidarum among pregnant women attending health care service in public hospitals of Southern Ethiopia. PLoS ONE 17(4): e0266054. https://doi.org/10.1371/journal.pone.0266054

Editor: Wubet Alebachew Bayih, Debre Tabor University, ETHIOPIA

Received: October 7, 2021; Accepted: March 11, 2022; Published: April 26, 2022

Copyright: © 2022 Ashebir et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ANC, Ante Natal Care; AOR, Adjusted Odd Ratio; CI, Confidence Interval; HEG, Hyper Emesis Gravidarum; NVP, Nausea and Vomiting of Pregnancy

Introduction

Pregnancy is an important period in which physiological, psychological, and social changes are experienced, and this requires adaptation to these changes. The process of adaptation to the role of pregnancy and motherhood varies depending on the individual’s memories, psychosocial economic, environmental conditions, wishes and physiological symptoms, complications resulting from pregnancy [ 1 ].

Nausea and vomiting of pregnancy (NVP) are very common in early pregnancy and it is considered as a part of normal physiology [ 2 ]. Up to 80% of all pregnant women experience some form of nausea and vomiting during their pregnancy [ 3 ].

According to The International Statistical Classification of Disease and Related Health Problems, hyperemesis gravidarum (HEG) is defined as ‘persistent and excessive vomiting starting before the end of the 22nd week of gestation [ 4 ]. It is characterized by persistent vomiting and nausea at least three times per day, weight loss of more than 5% of pre-pregnancy body weight, ketonuria, electrolyte abnormalities and, dehydration, resulting in a poor quality of life and increased health care cost [ 5 ]. Hyperemesis gravidarum is the most common cause of hospitalization during the first half of pregnancy [ 6 ].

A cohort study conducted in Nova Scotia, Canada revealed that hyperthyroidism disorders, psychiatric illness, history of molar pregnancy, pre-existing diabetes mellitus, gastrointestinal disorder and, asthma were associated with increased risk of hyperemesis gravidarum [ 7 ].

A cross -sectional study conducted in Egypt showed gastrointestinal diseases, urinary tract infection and multiple pregnancies were the most common risk factors of hyperemesis gravidarum [ 8 ]. Un-unmatched case-control study conducted in Bale zone hospitals, indicates that being urban residence, being employed, being in the first trimester and second trimester period and having perceived stress illness were associated factors of HEG [ 9 ].

In Norway about 25% of women with HEG want to terminate the pregnancy and 75% of them prefer to stop getting pregnant again [ 10 ]. In Botswana, 2.4% pregnant women died because of hyperemesis gravidarum [ 11 ]. In different parts of Ethiopia, the magnitude of hyperemesis gravidarum 4.4% in Addis Ababa [ 12 ], 4.8% in Jima [ 13 ], and 8.2% in Arba Minch [ 14 ] were diagnosed.

HEG adversely affects physical activities and work performance [ 15 ], family and social relationships [ 15 , 16 ], psychological status [ 16 , 17 ], nutrition [ 18 ], and health of women, decreases their quality of life and makes adoption to pregnancy is difficult [ 19 , 20 ].

Further, it causes serious complications like pre-eclampsia placental abruption, coagulopathy, neuromuscular complications organ damage, and even death [ 21 , 22 ]. Women will become dehydrated and no longer be able to provide the fetus with essential nutrients for growth which results in intrauterine pregnancy loss, growth restriction, intrauterine fetal death, preterm delivery, low birth weight, low 5-minute Apgar score, and increase risks of neural tube defects [ 23 , 24 ].

Identifying the determinants of hyperemesis gravidarum have a particular importance for early detection and intervention to reduce the health, psychosocial and, economic impact on the women and families. Despite having many studies done elsewhere, in Ethiopia little is known about the predictors of hyperemesis gravidarum. Therefore, this study aimed to identify determinants of hyperemesis gravidarum among pregnant women attending health care service in public hospitals of Gamo, Gofa, and South Omo Zones.

Methods and materials

Study setting and design.

An institution-based case-control study design was conducted in public hospitals of southern Ethiopia, from April 12 to June 12, 2021. In the southern region, there are 15 zones, the study was conducted in three zones of 9 public hospitals of Gamo, Gofa, and south Omo. Arba Minch town is the administrative city of Gamo Zone, which is 505 km far from Addis Ababa. Sawla town is the administrative city of Gofa Zone, which is 464 km far from Addis Ababa, and Jinka town, which is the administrative city of South Omo Zone and 755 km far from Addis Ababa, the capital city of Ethiopia. Currently, in Gamo zone there are five Hospitals (Arba Minch General Hospital, Chencha Hospital, Selamber hospital, Kemba and Gerese hospital). In Gofa zone there are two hospitals (Saula general hospital and Laha primary hospital). And South Omo zone has two public hospitals (Jinka general hospital and Gazer primary hospital).

Source population.

All pregnant women who attended health care services in public hospitals of Gamo, Gofa, and south Omo zones were the source population.

Study population.

Cases . Pregnant women in the antenatal period admitted with HEG in public hospitals of Gamo, Gofa, and south Omo zones during the study period were the cases.

Controls . Pregnant women attending antenatal care visit, and not diagnosed with HEG in public hospitals of Gamo, Gofa, and south Omo zones during the study period were the controls.

Exclusion criteria

Cases . Pregnant women who are severely ill and unable to respond for the interview were excluded from the study.

Controls . Pregnant women, whoever treated for HEG in the current pregnancy were excluded from the study.

Sample size determination and sampling techniques

The sample size was calculated by using EpiInfo version 7 menu StatCalc programs for four potential determinants which were significant in recent studies with the consideration of the following assumptions: confidence level 95%, power 80, and exposed to an unexposed ratio of 1:2. Which is taken from the previous study done in Bale zone, Ethiopia [ 9 ] on risk factors of hyperemesis gravidarum (by taking the factor being in the 2 nd trimester when severe NVP or HEG starts) and the largest sample size was 327, and 10% of the total sample size was added to compensate non-response rate and the final sample size was 360 (120 cases and 240 controls).

To get the required number of cases and controls, proportional allocation was done to each hospital based on the number of women admitted for HEG. Cases were selected every other mother (k = 2) until the sample size reached, for each case, two controls (k different for each hospital) were selected from pregnant women attending antenatal care visit by using systematic random sampling.

Operational definition

Hyperemesis gravidarum. Hyperemesis gravidarum refers to intractable nausea vomiting during pregnancy that leads to weight loss and volume depletion, resulting in ketonuria [ 25 ].

History of hyperemesis gravidarum: when pregnant women claimed or documented as she was ever diagnosed or treated for HEG at least once in the previous pregnancy.

Cases. Defined as women in antenatal period clinically diagnosed by the physician as being hyperemesis gravidarum.

Controls. Defined as the women in the antenatal period that had not been diagnosed with hyperemesis gravidarum.

Data collection tool and quality control

Data were collected from pregnant women attending health care service by using a structured face-to-face interviewer administered questionnaire and checklist for document review were used to collect the data from the study participants. Initially, it was prepared in English language then translated to the Amharic language and back to English to ensure consistency. The questionnaire contains socio-demographic characteristics, reproductive questions, medical factors, psychological factors and dietary factors. A 10 -item multiple-choice self-report psychological instrument was used for measuring the perception of stress. Each answer is scored 0 to 4, 0 –never, 1—almost never, 2 –sometimes, 3—fairly often, and 4—very often. Revers scoring was used for positive statement questions (4, 5, 6, and 7). It is scored by summing across all scale items. Scores ranging from 0–13 would be considered low stress, scores ranging from 14–26 would be considered moderate stress, and scores ranging from 27–40 would be considered high perceived stress [ 26 ].

Patient health questionnaire was used to assess depression; which comprises nine items that can be scored from 0 (not at all) to 3 (nearly every day). Scores ranging from 0–4 would be considered minimal depression, 5–9 mild depression, and 10–14 moderate depression, 15–19 moderately severe depression and 20–27 Severe depression [ 27 ]. Modified dietary history tool was used to assess dietary practice of pregnant women [ 28 ].

Two days training was given for nine data collectors and three supervisors. Then, pre-test was conducted on 5% [ 18 ] of the sample size. Cronbach’s Alpha was calculated by using SPSS software version 25 to test internal consistency (reliability) of the item, and Cronbach’s Alpha greater than 0.7 was considered as reliable and 0.949 for perceived stress illness and 0.839 for depression were obtained.

Data processing and analysis

The data were collected by KoBocollect version 1.3 then exported to statistical package for social science (SPSS) version 25 for analysis. Frequency distribution table was used to for presentation of data. Bivariable analysis, crude odds ratio with 95% CI, was used to see the association between each independent variable and the outcome variable. Independent variables with p-value of ≤ 0.25, biologically plausible and consistent in the previous study were included in the multivariable analysis to control confounding factors. Multicollinearity test was done before model fitness was assessed and VIF was less than 10. Hosmer and Lemeshow’s goodness-of-fit test was checked, and it was found to be insignificant (p value = 0.821) which indicate the model was fitted. Finally, multivariable logistic regression analysis was done to assess the determinants of hyperemesis gravidarum. Level of statistical significance was declared at p value < 0.05 with, 95% Confidence Interval.

Ethical consideration

The study obtained ethical approval from Arba Minch University, College of Medicine and Health and Sciences, Institutional Research Ethics Review Board (IRB/1078/21). Based on the approval, an official letter was written by Arba Minch University Public Health Department to each Zonal Health Department. Explanation on the objective of the research was provided to public hospitals administrators. Similarly, the administrators of each public hospital wrote letter to the concerned unit. Then the respondents were informed about the purpose and procedure of the study, the importance of their participation, the benefits, and risks associated with the study, the right to withdraw at any time if they feel discomfort. After explaining the purpose of the study, written consent was obtained. To maintain the confidentiality of information gathered from the study participant, code numbers were used throughout the study. During each contact with study participants COVID19 transmission prevention measures were taken. For each data collector single reusable mask was provided.

Socio-demographic characteristics of respondents

A total of 360 study participants (120 cases and 240 controls) were interviewed in the study. The mean age was 27.19 (SD±5.19) for cases and 26.53 (SD±5.33) for controls respectively. Nearly two third of women with hyperemesis gravidarum 89 (74.2%) and more than half of controls 147 (61.3%) were from urban areas. Ninety one percent of cases 109 (90.8%) and almost all controls 229 (95.4%) were married. Less than ten percent of cases 11 (9.2%) and thirteen percent of controls 30 (12.5%) have no formal education. More than two third of 81 (67.5%) cases and sixty three percent of controls 150 (62.5%) have no leisure time physical activity ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0266054.t001

Obstetrics characteristics of respondents

Almost all cases 115 (95.8%) and nearly three percent 6(2.5) of controls were in the first trimester period. The mean gestational age was 8.18(SD±2.86) and 25.52(SD±6.27) for cases and controls respectively. More than half of the cases 64(53.3%) and more than one-third of controls 99(41.3%) hadn’t the previous experience of pregnancy. The Majority of cases 103(85.8%) and controls 213 (88.8%) reported that their inter pregnancy interval was two years and above and the mean inter-pregnancy interval was 25.96(SD±5.67) months for cases and 28.34(SD±5.93) months for controls. Nearly one-third of cases 18(32.1%) and sixteen percent of controls 22(15.6%) had history of hyperemesis gravidarum. Regarding to the current pregnancy about two-third of cases 81(67.5%) and more than three-fourth of controls 211(87.9%) reported that their pregnancy was planned. While large proportion of cases 112(93.3%) and controls 231 (96.3%) reported that their pregnancy was wanted.

About forty-five percent of women with hyperemesis gravidarum 25(44.6%) and about quarter 35(24.8%) of women without hyperemesis gravidarum had bad obstetric history ( Table 2 ).

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https://doi.org/10.1371/journal.pone.0266054.t002

Medical histories of respondents

Sixteen percent of women with hyper emesis gravidarum 19(15.8%) and four percent 9(3.8%) of pregnant women without hyperemesis gravidarum had previous history of diabetes mellitus. About quarter of cases 30(25%) and five percent of controls 12(5.0%) had history of asthma or other respiratory tract infections. Ninety four percent of cases 112(93.3), and almost all controls 238(99.2%) had no history of hyperthyroid disorder ( Table 3 ).

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https://doi.org/10.1371/journal.pone.0266054.t003

Dietary characteristics of respondents

Nearly half of the cases 62 (51.7%) and three fourth of controls 174(72.5%) had a habit of eating snacks. More than-two third of cases 86(71.7%) and about half of the controls 125(52.1%) had a habit of eating spiced foods. More than three-fourth of cases 103(85.8%) and two third of controls 172(71.7%) had inadequate water intake. More than half of the cases 67(55.8%) and fifteen percent of controls 37(15.4%) weren’t iodized salt users during their pregnancy. Nearly half of the cases 57 (47.5%) and fifteen percent of controls 35(14.6%) hadn’t ginger intake during their pregnancy. More than three-fourth of women with HEG 99(82.5%) and nearly half of controls 113(47.15%) had a history of saturated fat intake. Nearly three-fourth of cases 87(72.5%) and half of the controls 121(50.4%) hadn’t adequate intake of vitamin B reach foods during their pregnancy.

Determinants of hyperemesis gravidarum

Bivariate logistic regression was done between independent variables and HEG to identify candidate variables for multivariable logistic regression. residence, educational status, marital status, occupation, having polygamous husband, gravidity, history of Asthma/other respiratory tract infection, planned pregnancy, supported pregnancy, saturated fat intake, intake of vitamin B reached foods, ginger intake, water intake and eating seasoned foods had association on bivariate analysis. Those variables with a P value of ≤ 0.25 in the bivariate analysis was entered to multivariable logistic regression model.

The result showed that, the odds of developing hyperemesis gravidarum was 2.1 (AOR = 2.1, 95% CI: 1.01, 4.34) times higher among urban dwellers as compared to rural dwellers. Mothers having polygamous husband were 2.92(AOR = 2.92, 95% CI: 1.27, 6.68) times at higher odds of developing HEG as compared to their counter parts. The odds of developing HEG was 3.56 (AOR = 3.56, 95% CI: 1.43, 8.82) times higher among Mothers having history asthma as compared to having no history of asthma or other RTI. The odds of developing hyperemesis gravidarum among pregnant women who had history of saturated fat intake was 4.06 (AOR = 4.06 95% CI: 1.98, 8.3) times higher as compared to had no history saturated fat intake. Pregnant women who had no intake of ginger were 3.04 (AOR = 3.04 95% CI: 1.14, 8.09) times at higher odds of developing HEG as compared to their counter parts. The odds of developing hyperemesis gravidarum among was 2.2(2.2, 95% CI: 1.14–4.2) times higher among pregnant women who had no adequate intake of vitamin B reach foods as compared to those who had adequate intake of vitamin B reach foods ( Table 4 ).

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https://doi.org/10.1371/journal.pone.0266054.t004

The finding of this study revealed that urban residence, having polygamous husband, having history of asthma/other RTI, Intake of saturated fat, no intake of ginger, and inadequate intake of vitamin B reach food were the determinants of hyperemesis gravidarum.

The result indicates that, the odds of developing hyperemesis gravidarum were two times higher among urban dwellers as compared to rural dwellers. This result supported by previous studies conducted in bale Zone hospitals [ 9 ], on the other hand, this finding is in contrast with the findings of studies conducted in Turkey [ 29 ], which concludes that there are no statistically significant differences between cases and controls concerning the residence. The possible explanation might be due to the difference housing conditions, environmental sanitation, sewerage system, and ventilation between turkey and Ethiopia [ 30 ].

Mothers having polygamous husband were three times at higher odds of developing HEG as compared to their counter parts. But this result is, on the contrary, to the study conducted in the Batman State Hospital, which showed that, there are no statistical differences between cases and controls in terms of having a polygamous husband [ 31 ]. This might be due to a difference in moral acceptability of polygamous marriage by the community and also care and support given to the women by the polygamous husband. Polygamous marriage can reduce self-esteem, marital satisfaction, and leads to marital conflict, somatization, depression, and anxiety; in turn those psychological problems can induce nausea and vomiting during pregnancy.

The odds of developing HEG were four times higher among Mothers having history asthma as compared to having no history of asthma or other respiratory tract infection. This result is in agreement with the study conducted in Nova Scotia, Canada [ 7 ], which concludes that pregnant women with past medical history of asthma and other respiratory disorders were found to be more liable to hospitalization due to HEG. The possible reason for this might be those women who had asthma can have a severe cough, during uncontrollable cough, repeated chest muscle contraction and relaxation puts pressure and disturb the stomach and finally it can trigger nausea and vomiting [ 32 ].

The odds of developing hyperemesis gravidarum among pregnant women who had a history of saturated fat intake were four times higher as compared to had no a history saturated fat intake. This study is in line with the study conducted in Boston, which found that Mothers having a history saturated fat intake were three times at higher odds of developing HEG compared to having no a history of saturated fat intake [ 33 ]. The possible explanation for this finding goes to the effect of saturated fat intake on circulating estrogen level. Saturated fat has been shown to increase circulating levels of estrogen. If the liver is clogged with too much saturated fat, it will have a hard time to breaking down estrogen in the body and estrogen will recirculate leading to the estrogen excess [ 34 ]. Estrogen contributes to HEG by stimulating the production of nitric oxide via nitrogen oxidase synthase, which in turn relaxes smooth muscle, slowing gastric intestinal transit time and gastric emptying [ 35 ]. A diet high in saturated fat also triggers inflammatory bowel diseases, consequently women more likely to experiencing nausea and vomiting [ 36 ].

Pregnant women who had no intake of ginger were three times at higher odds of developing HEG compared to have intake of ginger always. This result supports the report of a meta- analysis and literature review [ 37 , 38 ]. Which concludes ginger is an effective preventive and non-pharmacological option for the treatment of hyperemesis gravidarum. This may be related to the blocking effect of ginger on receptor cells. Ginger can antagonize activation of m3 muscarinic receptor and serotonin(5-HT3) receptors, thereby inhibiting afferent inputs to the central nervous system that are stimulated by specific neurotransmitters, released from the gastrointestinal tract [ 39 , 40 ]. Ginger also important for the digestion process, it works increasing Agni or ’digestive fire’, which further helps to better break down and assimilation of food. Apart from this, ginger is also known to stimulate saliva, bile and gastric enzymes that aid digestion and help speed the movement of food from the stomach to the small intestine [ 41 ].

The odds of developing hyperemesis gravidarum was two times higher among pregnant women who had no adequate intake of vitamin B reach foods as compared to those who had adequate intakes of vitamin B rich foods. This result supports the findings of the research conducted in Sweden [ 42 ] which indicates that 28 percent of pregnant women who had intake of vitamins in early pregnancy were at low risk of developing HEG. This finding also in line with the study conducted in Norway [ 43 ] which showed that adherence to a vitamin b rich diet associated with a lower risk of developing hyperemesis. Vitamin B helps to prevent nausea and vomiting by prevent infections, promote healthy brain function and regulate and promote good appetite, and facilitates/ease the digestion process by breakdown carbohydrate, fats and alcohol [ 44 ].

This study found that urban residence, having polygamous husband, history of asthma/other respiratory tract infection, intake of saturated fat, no intake of ginger, and inadequate intake of vitamin b rich foods were important determinants of hyperemesis gravidarum. Healthcare providers should exert continual effort to give health education and counselling service concerning to dietary practice and asthma attacks. It is better if pregnant women adhere to healthy diets and limit intake of saturated fats and it is crucial to create awareness about the health hazards of saturated fat intake on health of pregnant women through multiple communication channels.

Supporting information

S1 file. data collection tool..

https://doi.org/10.1371/journal.pone.0266054.s001

S2 File. The dataset used for this study.

https://doi.org/10.1371/journal.pone.0266054.s002

Acknowledgments

The authors thank all the study participants and data collectors.

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A case study approach to Hyperemesis Gravidarum: home care implications

Affiliation.

Clients with Hyperemesis Gravidarum (HG) have nausea and/or vomiting that prevents adequate intake of food and fluids. A client could have weight loss, dehydration, nutritional deficiencies, metabolic deficiencies, difficulty with daily activities, psychosocial stress and depression. Managing a client at home with HG is very complex and requires a multidisciplinary approach.

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    Background Hyperemesis gravidarum is severe nausea and excessive vomiting, starting between 4 and 6 gestational weeks, peak at between 8 and 12 weeks and usually improve and subside by 20 weeks of pregnancy. Identifying the determinants of hyperemesis gravidarum has a particular importance for early detection and intervention to reduce the health, psychosocial and economic impact. In Ethiopia ...

  11. A case study approach to Hyperemesis Gravidarum: home care implications

    Abstract Clients with Hyperemesis Gravidarum (HG) have nausea and/or vomiting that prevents adequate intake of food and fluids. A client could have weight loss, dehydration, nutritional deficiencies, metabolic deficiencies, difficulty with daily activities, psychosocial stress and depression.